=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639495310
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOOBIN GHAHREMANI DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2010
-----------------------------------------------------
Last Update Date | 04/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1725 W 6TH ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90017-1000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-679-3153
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4705 WHITSETT AVE APT 206
-----------------------------------------------------
City | STUDIO CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91604-1156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 59174
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 107252
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------